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Anemia
(尚未整理) Anemia 長庚 * MCV= Hct/RBC < 80fl 定義 * Hct= MCV * RBC 現今 小血球性貧血 (microcytic anemia)，而答案中A的缺鐵性貧血與B的輕度地中海型貧血 (thalassemia trait)，都是可能的原因。 這兩種常見的小血球性貧血，可以藉由MCV與紅血球計數的比值得知比較可能的診斷。算法為：(MCV X 106)/紅血球計數 (/dL)，此數值超過13者，比較可能是缺鐵性貧血；此比值低於12者，比較可能是輕度地中海型貧血。問題中病例的此數值為11，所以是輕度地中海型貧血的可能性最高。 Microcytic * IDA, thalassemia, anemia of chronic disorder (ACD) * Anemia > WBC?PLT? > pure anemia > IDA, thalassmia, ACD Thalassemia * RBC count high, retico mild increase, RDW% elevate depend on the severity of thalassmia, Target cell not specific * HbA: >97% * HbA2: <3% * HbF: 0% in adult * HbH: minimal in electropheresis, use Hb H staining (只有北榮在做) to detect * Hb H disease- large amount of HbH when 3 gene deletion alpha-thalassmia. But HbH will be made in all alpha-thalassmia. * Fe Sat is only valuable when elevated TIBC Iron deficiency anemia * plt high, cause unknown, RDW-CV% high in early stage, 15-20% mild leukopenia cause unknown * Low ferritin without anemia: should treat *# Iron depletion: graudally ferritin level, others normal *# IDA: low ferritin, low Fe, high TIBC/UIBC, low iron sat (Fe/TIBC) * Combine Thalassmia and IDA ** thalassemia easy iron overloading, only in moderate to severe case, we can still add Fe to thalassmia minor + IDA patient anenmia of chronic disease * Feature: nil * Impaired utilizatiun of iron, low serum iron and low TIBC, normal or high ferritin * Malignancy, chronic inflam, chronic infection * Tx of underlying dz, avoid erroneous supplementation of iron Macrocytic Anemia * Reticulocytosis make MCV elevated * We should check reticulocyte count in high MCV patient Reticulocytosis * emergency indicator, check LDH + Bil (T/D) * Hemolysis makes inderect bil elevated, but the mount of T.bil will not over 5 mg/dl in pure hemolysis * Urine OB (+), Urine RBC (-), U hemosiderin (+), Direct Coombs' test positive -> AIHA * Comb' neg hemolysis: consider TTP Megaloblastic * B12 (major), folic acid deficieny (rare), DNA metabolic impair > Pancytopenia, (leuko < 2000, rare in pure case), (plt < 20000, rare in pure case) * RBC raptured in bone marrow, d/d with hemolysis by reticulocyte count, LDH isoenzyme * Caustion when Young female with macrocystic anemia Myelodysplastic * Myeoloma- usually pure anemia * Pancytopenia > BM * BM: severe hypocellularity > AA * BM: severe hypercellularity blasts 15% > MDS * BM: severe hypercellularity blasts 80% > "Aleukemic leukemia" * BM: severe hypercellularity, good maturation? > Impossible Auto-Immue Hemolytic Anemia (AIHA) * is not a final diagnosis * SLE, CLL, lymphoma, MM ICD9: 283.0 中文：自體免疫溶血性貧血 CBC-Anemia * WBC ** DC-man counting good but machine counting poor ** DC in post C/T, Seg/Lym 1/19, Seg/Lym/Mono ?/10/10 indicate WBC generation → Seg predominat → WBC increase through 500,1000 * Plt 150k-40k * Hb M14, F12 at least * MCV 80-100FL ** 小球性貧血: IDA, thalathemia, ACD, 鉛中毒... * RBC number: M 4.7-6.1, F 4.2-5.4 ** RBC number much more Hb → thalasemia, espi in Hb > 8 * MCV to d/d IDA(big), thala(micro) * RDW: thala in Normal range, IDA large * PLT: some IDA patient has mild thrombocytosis * WBC: some IDA pt has mild neutropenia * Hb electrophoresis ** HbA2 > 3.5 → beta thala ** if HbH → alpha thala ** HbH stain → 1-4+ alpha thala, more sensitive than electrophroesis * Iron overload > 60% ** Ferritin, iron, bone marrow iron stain * (reticulocyte is larger than RBC, Make MCV larger) * Macrocytic anemia ** Case Pancytopenia, MCV 135(macro) ** Reticulocytosis, AA, M dysplasia Syndrome, liver dz, endocrime dz * Reticulocytosis, check Reticulocyte count → acute bleeding, acute hemalysis, regeneration BM (treating IDA, B12 defi about 1 wk to peak, Hb increase in 2wk, treat B12 1 shot/Day in 1wk, 1 shot/wk...) * Megalo → CBC no use, SMAC good * 無效造血>髓內溶血, LDH ↑↑ , T.bil, D.bili ↑ * D/D AIHA autoimmue hemalysis anemia: check LDH iso-enzyme (LDH 2) Megalo(LDH 1) * (LDH 1 has 2 dz: Megalo, AMI) * MDS 輕微骨內溶血, LDH ↑ , PLT-- * Normocystic * ACD, renal anemia, AA, MDS, endocrime * Renal anemia, EPO related * Chronic disease anemia, no good diagnosis tool * SMAC: Alb low, Ca 10.8, corret: Ca-Alb +4 * Multiple myeloma: anemia, poor renal function, hyper Ca++, check immunoglobin IGGAM Hemolysis * Acute anemia, * anemia+ jundice * lab: Ret, I.bil * comf ** Ret 1,2,3 days ** LDH (LDH2) ** free Hb in plasm, urine if large intravescular hemolysis ** I.Bil > 80% T.Bil ** T.bil < 18 mg/dl * etiology # Immue (coomb +) > Steroid # Non immue (coomb-) > blood smear, HS?, HE?, target cell?, fragment RBC? (MAHA-TTP, DIC,), Normal RBC (G6PD....) 其他連結 wikipedia:Anemia